Friday, April 25, 2014

“Given that primary care doctors do the work that no one else is willing to do, being a primary care physician is more like being a janitor—but without the social status or union protections” writes internist Daniela Drake. She asserts that being a doctor “has become a miserable and humiliating undertaking” and that many believe that, “America has declared war on physicians.” And this: “It’s hard for anyone outside the profession to understand just how rotten the job has become.”

Some of her complaints (rants) may have some merit—physicians, especially primary care physicians—are undervalued, relative to other specialists, and they are drowning in paperwork that saps their professional satisfaction and takes time away from their patients. But let’s get real: doctors are still among the most highly respected and highly paid occupations in the United States. By comparing primary care to being a janitor, Dr. Drake demeans both her own chosen field and the hard-working people who work nights mopping her practice’s floors and cleaning its toilets.

Here are the facts. According to a new Medscape salary survey, internists who specialize in primary care earned an average of $188,000, and family physicians, $176,000 in 2013. Yes, that’s near the bottom of all specialties’ earnings, but still more than 90% of Americans earned. And if you are a primary care physician in a household with an income of $232,000 or more, which is the case for many whose spouses also work, you are in the top 5 percent! To put this in perspective, “If you're in a family of four, and your family's income surpasses $66,000 a year, you're doing better than the typical American family. If you're making six figures, then you're doing much better than the typical American family. If you're making $200,000 or more, you're in truly rarified territory” reports the Washington Post. The Bureau of Labor Statistics reports that the mean annual wage for janitors was $25,140. The Census Bureau reports that median household income, all occupations, was $51,000 (2012 data).

And, perhaps surprisingly, primary care physicians overall aren’t that much more dissatisfied with their pay than other physician specialists, a new study finds. “Primary care physicians were only slightly more negative [about their compensation] with 52% saying they did not feel fairly compensated while 48% did with their pay,” reports Medscape. “Considering the ongoing income disparities between primary care physicians and specialists, their having the same perception is somewhat interesting. There has been very little change in the responses to this question over the past 3 years.”

Lack of social status? Actually, physicians rank third, behind members of the military and teachers, as the most respected professions. “Roughly six-in-ten or more adults also say that medical doctors (66%), scientists (65%) and engineers (63%) contribute a lot to society. As with the military and teachers, negative perceptions of these occupations are comparatively rare.” Lawyers are at the bottom of the public’s respect ranking, say the researchers at Pew. The Gallup organization finds that 69% of the public rank physicians highly on ethics and honesty; nurses score the highest at 82%, followed by pharmacists (70%), grade school teachers (70%), and then physicians. Lawyers, again, were near the bottom, with only 20% of the public saying they were honest and ethical.

So, Dr. Drake may not respect her own profession, but the public clearly does. And by any standard, physicians—even primary care physicians—are in the top ranks of compensation.

This is not to say that there isn’t real heartache on the front lines of medicine. According to Medscape, Internal medicine physicians are the most likely (68%) to say they would choose medicine as a career if they had to do it all over again, but internists are last (27%) in saying they would choose the same specialty. One likely reason is the amount of time that internists and other primary care physicians have to spend on paperwork. “According to this year's compensation survey, 35% of employed physicians spend at least 10 hours a week on paperwork compared with 26% of the self-employed” reports Medscape.

Yet most physicians still like being physicians. “Despite the frustrations, most physicians find their careers deeply rewarding” says Medscape. “Being good at their jobs (34%) and relationships with patients (33%) were cited most among those who responded. Twelve percent chose "making the world a better place." Simply being proud to be a doctor (6%) and making good money (10%) were less compelling factors.”

So no, Dr. Drake, most of your colleagues aren’t miserable. Most are not leaving the field. Only 3 percent are in concierge practices, Medscape found.

Fortunately, there are physicians who are willing to directly rebut Dr. Drake’s views. Dr. Aaron Carroll, a professor of pediatrics, penned this:

“Monday night, at the Seder we were attending, we all discussed things for which we were thankful. I acknowledged my thanks for my family and friends, and then said that I was very, very grateful to have a job which I found so utterly rewarding and fulfilling. Evidently, Daniela Drake disagrees with me . . .

I’ve written about this again and again, and I don’t want to repeat myself more than I have to. I think physicians complain far more, and far more publicly, than their situations warrant. For all their complaints, they still do incredibly well financially. They have more professional freedom than most working people. And they’re beloved.

Moreover, tons and tons of people want to be them. Applications remain at an all time high for medical school.

. . . I’ve been around physicians for all my life, and for the entirety of it, I can remember many of them complaining. I can remember many of them complaining even while they made fortunes, lived fantastic lives, and had fulfilling careers. I remember many of them threatening to quit. None did.

I imagine that a fairly large number of Americans work just to get a paycheck. They find their jobs to be dull and unfulfilling, should they be lucky enough to have them. Being a doctor is a great gig, and I don’t really know any who would give it up to punch a clock or go do something else. I know some who’d threaten to do so, and some who wish things were better, but the number of them who follow through and abandon the field is near zero. At some point, people are going to ignore the cries of ‘wolf’. Other than bankers, is there any profession doing so well overall that complains so much in the media?”

Like Dr. Carroll, I also have been around physicians almost all of my life, although I am not one. I have spent my entire career, over 35 years now, advocating for the medical profession, and specifically, for internists, first with the American Society of Internal Medicine and since 1998, with ACP. Every day, my colleagues and I on the ACP staff work to address the aspects of their jobs that are professionally unrewarding, especially excessive administrative burdens and a payment system that undervalues them compared to others. So I sympathize with some of Dr. Drake’s complaints.

But I also know that engaging in public expressions of self-pity isn’t going to help physicians, nor is hyperbole. Comparing a highly compensated and respected profession, doctors, with one of America’s most marginalized and least respected, janitors, isn’t going to make any friends for physicians.

Today’s questions? What do you think of Dr. Drake’s comparing being a primary care physician to a janitor “without the social status?” And Dr. Carroll’s rejoinder that being a doctor is still a great gig?

Tuesday, April 22, 2014

During ACP’s annual meeting in Orlando a few weeks ago, the College released a new position paper on reducing injuries and deaths from firearms—the first comprehensive update of College policy since the late 1990s. (I am a co-author of the paper.)

Published as an online-first article in the Annals of Internal Medicine (publication in print to follow soon), the paper is the result of an extraordinarily comprehensive review of the evidence of the causes and solutions to firearms-related injuries and deaths in the United States conducted by ACP staff and its Health and Public Policy Committee. (Of note, the members of HPPC included several internists who themselves own firearms.) A team of four reviewers examined over 120 studies and utilized CDC, ATF and other databases.

A draft of the paper was reviewed by outside experts in mental health and firearms issues, by expert reviewers selected by the Annals of Internal Medicine, and by ACP's Board of Regents, Board of Governors, and Councils during a 45-day review period; appropriate revisions were made in the final draft to address the substantive comments from reviewers. The paper was approved by the Board of Regents on April 7, 2014.

As we developed our recommendations, we had one simple standard: what does the published evidence say about the causes, effects, and prevention of firearms injuries and deaths? (To read about all of the evidence behind our recommendations, click on the link in the executive summary to appendix 1.)

In assessing the evidence, we identified where the evidence was strongest before we advocated for a particular policy recommendation, where it was weakest, and where more research is needed.

Our paper found strong evidence that having firearms in the home is associated with a greater risk of deaths and injuries (accidents, homicides, suicides combined) especially when children, adolescents, people with mental illness, and drug and alcohol abusers are present. It found strong evidence for treating firearms violence as a public health issue. for universal background checks, for subjecting firearms to consumer safety standards, for incorporating safety features like trigger locks, and for firearms owners themselves adopting best practices to reduce the risk of accidental or intentional injuries and deaths from their guns.

We also found that, although there is limited evidence that banning future sales of firearms with features that allow them to kill as many people as possible, as quickly as possible (commonly called “assault” weapons and certain types of semi-automatics) and large capacity ammunition would be effective in reducing overall homicide rates, such a ban would be warranted to reduce casualties in mass shooting situations.

We also found very limited evidence that waiting periods are effective in reducing overall homicide rates from firearms although there is evidence that waiting periods may be effective in reducing suicides. We found limited evidence on the impact of concealed carry laws in increasing or reducing deaths and injuries from firearms. We called for better access to mental health services while calling for more research on the impact of laws requiring physicians to report persons with mental illnesses who may be a risk to themselves or others.

A companion original research paper published in Annals found that ACP’s policy prescriptions had strong support from large majorities of surveyed ACP members. Although members’ views are of obvious interest to us, the policy paper was not based on the opinion survey, but on the published evidence on what is effective in reducing firearms injuries and deaths.

Predictably, the National Rifle Association (NRA) unloaded over on ACP’s recommendations, calling us “the anti-gun” American College of Physicians. It linked release of ACP’s policy paper to the fight confirming Dr. Vivek Murthy, an ACP member, who has been nominated as Surgeon General but whose confirmation vote has been put off because of strong NRA opposition. (ACP strongly supports Dr. Murthy’s nomination—and he is absolutely right that firearms injuries and deaths are a public health issue—but release of our position paper was purely coincidental and unrelated to his nomination.) “Murthy's nomination is currently on hold, due to concerns about his true motives for seeking the Surgeon General's post” says the NRA. “The ACP's endorsement of massive federal gun control only underscores how well-founded those concerns really are.”

Anti-gun? Massive gun control?

ACP’s policy recommendations are neither pro nor anti-gun; they are pro-gun safety. Our paper acknowledges that any regulations must be consistent with the Second amendment right to bear arms. We do not propose banning any guns, except certain types of semi-automatics that have features that would allow a mass shooter to kill as many people as possible as quickly as possible, as well as high capacity ammunition clips. Closing the “gun show loophole” in the current background check system would ensure that prohibited purchasers, such as felons, persons involuntarily committed for mental illness or otherwise “adjudicated mentally defective,” cannot own firearms because of the risk they present to themselves and others.

Unlike the NRA, we followed the evidence on what will be effective in reducing firearms injuries and deaths, resulting in a common-sense and scientifically rigorous position paper. We encourage all physicians to read our paper and speak out for evidence-based policies to reduce the number of Americans—32,000 a year, 88 per day—that are killed by firearms, and the 74,000 that are injured each year by a gun.

Today’s question: What do you think of ACP’s policy paper and the NRA’s response?

Thursday, April 17, 2014

While I was at ACP’s annual scientific meeting in Orlando last week, the big news, unrelated to the meeting itself, was CMS’s decision to release a massive amount of data on what Medicare paid out in 2012 to each U.S. physician.

What is now commonly referred to as the CMS “data dump” created quite a stir—reactions from ACP members ranged from angst (“Why did this happen? How will the data be used? What will my patients think?”) to acceptance (“What’s the big deal? I don’t mind if the public knows how much Medicare paid me, I have nothing to hide”). The first thing that many attendees did was to download their own data, something made easy by a tool created by the New York Times to look up a physician by their last name and town (or zip code) and then extract the data from CMS’s files (working directly with the CMS data file itself is a ponderous process). Most I spoke to thought their numbers looked “about right” to them, although a few said there were inaccuracies in their own profiles.

Did the data dump show that any particular physician was guilty of fraud and abuse? Did it show that any particular physician was over-charging the program? Or that that a particular physician had ordered too many tests, drugs, and procedures? Did it provide any useful information about the quality of care provided by each physician? Or about the kinds of patients each physician treated and how sick they were? The answers are: no, no, no, no, and no!

It was just a raw data dump, showing how much Medicare paid out to each physician for some of their Medicare patients (patients enrolled in Medicare Advantage plans were not included), not how much physicians actually took home from Medicare (because the data did not subtract overhead, like the costs incurred by oncologists for chemotherapy drugs dispensed in their offices). Because the data included only what it was paid out per physician, without any context or adjustment for expenses, case mix, or quality, it is simply impossible to draw conclusions from the data about the appropriateness of the care provided by any particular physician. It certainly is not possible to conclude that any particular physician, including the outliers who received the most total dollars from Medicare, were guilty of fraud and abuse—only a court proceeding can prove a violation of law.

Yet much of the attention in the press was initially directed at Medicare's top-paid doctors, as Fox News called them the, “344 physicians who took in at least $3 million apiece for a total of nearly $1.5 billion.” Follow-up press coverage found that in some cases the high payments that were assigned to a single physician actually reflected payments to thousands of them. The New York Times, in an article titled “The Medicare Data’s Pitfalls,” reported on “Dr. Jean M. Malouin, a family medicine physician at the University of Michigan Health Systems, [who] shows up as one of the top Medicare billers in the country, collecting payments of $7.58 million in 2012 for more than 207,000 patients. But Dr. Malouin directs a Medicare project that involves 1,600 primary care physicians, who each receive a small payment each month. Those payments are funneled through Dr. Malouin. The doctor’s situation is described in a website that the hospital set up on Wednesday to help explain the data to the public.”

The same article quotes ACP’s new President, Dr. Dave Fleming, on the limitations of the data. “One concern is that this is a huge data dump, and a lot of interpretation is occurring without the data actually being analyzed, with exposure of physicians who have been paid huge amounts of money. I understand the implications, but there may be very legitimate reasons as to why.”

This isn’t to say that some of the top paid doctors don’t have some explaining to do, and at least one of them is being investigated by authorities for potential fraud and abuse. And patients might legitimately want to ask why their physician is an outlier. Further analysis will likely show that some outliers can’t be justified because of differences in case mix or other legitimate factors. But it is a leap too far to assume from the raw data dump that a doctor is guilty of behaving badly, never mind criminally.

The data is most useful in analyzing trends and outliers, by specialty and region, to inform public policy. Bloomberg News has a nice chart that shows the Medicare pay-outs by specialty and not surprisingly, internal medicine as the specialty that received the most Medicare dollars, more than $8.7 billion, because there are more internists treating more Medicare patients than other specialties. The average Medicare payment per internal medicine physician, though, was only $95,466. The top four specialties, with average payments of more than $300,000 per doctor, were hematology/oncology, radiation oncology, medical oncology, and ophthalmology. Yet the data dump amounts for oncologists and ophthalmologists include Medicare payments for the drugs (chemotherapy, and medications for macular degeneration) physicians in these specialties typically purchase and dispense in their offices, with most of the money going to the drug manufacturers, not the doctors. Medicare limits physicians to a 6 percent mark-up on the drugs they buy, which some suggest may itself create an incentive for physicians to prescribe the most expensive drugs.

“Doctors make a markup when they buy a drug and then use it” writes New York Times reporters Andrew Pollack and Reed Abelson . “Medicare is supposed to pay 6 percent over the average price of the drug. That percent represents a larger number of dollars for an expensive drug than for a cheap one. Retina specialists talk of colleagues who earn huge amounts of frequent flier miles by buying Lucentis using credit cards.”

Transparency is here to stay, and the American College of Physicians believes that the public has a right to know where their taxpayer dollars and premiums are going, including how much their physicians are receiving. Such data can help shine the light on why there are variations between and within specialties, regions and individual physicians in what they are receiving from Medicare and other payers, leading to policies to address variations that are not justified. In the right context, such data can help inform consumers about their choice of physician—if combined with reliable data on quality, outcomes, patient experiences with the care provided, and adjusted for case mix and overhead. Physicians should have the ability to review the data before it is released, and get corrections if it is inaccurate.

Most importantly, when raw data are released to the public on how much physicians are paid, or on the quality of care they provide, it needs to be accompanied with explanations on the usefulness and limitations of the information available. Medicare could, for instance, have released the data to the public with an explanation that it only showed the amount paid out to individual doctors, before overhead, not how much they actually took home; that it did not adjust for differences in the patient population being treated; that in some cases, if the billings of multiple physicians were assigned to a single physician; that physicians were not given the opportunity to review the data for accuracy and context (and seek corrections) before it went out, that the data included only traditional Medicare and not Medicare Advantage, that some specialties treat more Medicare patients than others and will therefore have higher average billings, and that the data are most useful for research on trends to inform public policy, not for making a judgment about an individual doctor's charges or quality or fraud and abuse.

By not doing so, Medicare made the data less useful than it could have been, unfairly tarred some physicians, and mislead the public. The government needs a smarter approach to transparency than just dumping raw data without context on the public and physicians.

Today’s questions: what do you think of Medicare’s data dump? Have your patients asked you about it? What are you telling them? Have you looked at your own data—and is it accurate?

Tuesday, April 1, 2014

When the clock struck midnight last night, the United States saw something it hasn’t seen in a very long time: bipartisan consensus to make the health care system better. After first voting for another Medicare SGR patch, the Senate came back late in the evening, and with the support of Senate Majority Leader Harry Reid and Minority Leader Mitch McConnell, the Senate reconsidered its early vote for a temporary one-year patch and instead voted out the bipartisan and bicameral permanent SGR repeal and Medicare physician payment reform bill previously agreed to by the Senate and House Medicare committees. On the other side of the Capitol, Speaker John Boehner and Minority Leader Nancy Pelosi agreed to immediately enter into negotiations with the Senate on how to pay for the bill. “We blew it last week when we used a parliamentary sleight-of-hand to pass the patch” Speaker Boehner told the Washington Post. “Patients and their doctors deserve better. This time, we will do the right thing and find a way to get an agreement with the Senate on permanent SGR repeal. Yes, it will be tough, but that is why we are here, isn’t it?”

The other sea change occurred when it appeared that Republican leaders took heed of the latest Obamacare enrollment numbers and dropped their insistence on repealing the law. “Look, we can count the numbers” said one highly placed GOP strategist” in a phone call with this blogger. “Despite the debacle with the government website, it is now looking like enrollment in Obamacare’s marketplace plans may meet or exceed the original target of 7 million. All along, the GOP strategy has been based on the idea that people will vote with their feet and reject Obamacare, with a nudge from us” he continued, “but they haven’t. Total Obamacare enrollment, including the marketplace plans, young adults on their parents’ plans, and Medicaid, may fall between 13 and 16 million people this year. And it appears that more than 9 million of them were previously uninsured, and that number will grow as more sign up for Medicaid during the year. And fewer than one million of the people whose insurance was ‘canceled’ actually lost coverage. So yeah, we get it, we won’t win by kicking all of these people off Obamacare. We have our work cut out for us though in persuading our Tea Party base to let go of repeal.” On the record, Republican leaders were more muted, with Senator McConnell noting that he was hearing from large numbers of Kentucky residents who were benefiting from Obamacare, “Yes, I hear them. I still think Obamacare is a mistake—we could have helped a lot of folks with a lot less money. If it was up to me, I would start over and pass something different. But it is clear now that the law is here to stay, so I will reach out to my Democratic friends and President Obama to seek common ground on how to make it better. “

A relieved but chastened President Obama said “Make no mistake, I blew it when I told everyone they could keep their health plans. I blew it by the disastrous roll-out earlier this fall. Yet somehow, people still signed up in droves, exceeding my own downsized expectations. We can make it better though, and today I pledge to reach out to my Republican and Democratic friends in Congress to find bipartisan approaches to improve it.”

Okay, April Fools—most of the above didn’t happen. The Senate joined the House in passing a one-year SGR patch instead of permanent repeal and reform of the physician payment system. There was no agreement between the chambers to enter into negotiations on passing and paying for the bipartisan and bicameral repeal bill that was agreed to by their Medicare committees. There was no admission by congressional leaders that they made a mistake by pushing through a patch. Read ACP’s statement (this one’s for real) on the Senate vote.

There was no indication that Republicans are re-thinking their Obamacare repeal demands—if anything, they are doubling down, believing that it is their ticket to re-taking the Senate in the 2014 mid-terms. No pledge to work with the President to improve it. No new admissions of fault by President Obama and efforts to reach out to Congress to improve it.

Yet this part is true: Enrollment in the ACA marketplace plans as of last night’s “soft” open enrollment deadline was projected to near or exceed the original (pre-website debacle) target. Charles Gaba, who has had a remarkable record of accuracy in totaling up Obamacare enrollment, estimates that total ACA enrollment—qualified plans bought on the marketplace, qualified plans bought outside of the marketplace, Medicaid, and young adults on their parents’ plans—reached between 14.6 and 22.1 million people. A new study estimates that nine and a half million of them were previously uninsured and fewer than a million of those whose health plans were “cancelled” still do not have coverage that meets the law’s requirements. Yet the ACA’s critics are still in denial about the ACA enrollment surge, argues New Republic’s Jonathan Cohn.

As I wrote a month ago in my Philadelphia Inquirer blog, caution is in order in drawing conclusions too quickly on the Obamacare enrollment numbers. Yet all indications are that enrollment will be on the high side, and more than 10 million previously uninsured will get covered in 2014, a potentially remarkable achievement given all of the obstacles (ones the administration imposed on itself, like the initial failed launch, and ones created by the unrelenting opposition to the law including the efforts in many states to impede enrollment).

In that sense, today is a banner day for U.S. health care, no foolin’. Just think of how much better it could have been if only the rest of this blog were true, if Congress decided to get rid of the SGR rather than just patch it, and if Republicans and Democrats alike, Congress and the President, called a cease-fire on Obamacare repeal and worked instead to find bipartisan ways to improve it. If only.

Today’s question: what do you think about the developments over the past 24 hours on the SGR and the ACA (the true parts) and what might have been?